Orange County Care Home II

Allegation investigated: Facility staff is engaging in retaliatory conduct against a resident Staff is being verbally inappropriate in front of facility residents Facility staff did not report health incidents appropriately to licensing staff Facility staff did not notify a resident's responsible party of a serious health incident

On this day, Licensing Program Analyst made an unannounced visit to the facility for the purpose of following up on the investigation of the four allegations listed above as well as to deliver findings to the facility. LPA was greeted and granted entry by administrator Faith Rasouli after stating the purpose of the visit. Allegations under review were listed during the visit. Administrator had to leave the premises during the visit and authorized care staff to sign on her behalf. An initial complaint investigation visit was conducted on June 17, 2025. During the visit, LPA accompanied by facility staff conducted a tour of the facility's physical plantas well as interviewed residents and witnesses. Resident records were requested and obtained. A follow-up visit took place on September 25, 2025. During the second visit, LPA conducted three staff interviews and five resident interviews. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM LIC9099 Regarding the allegation that Facility staff is engaging in retaliatory conduct against a resident, the following has been concluded: Multiple communications from facility staff were made to the responsible party for resident R1 to inform them of the potential need to seek alternate placement due to the growing inability of facility staff to provide adequate care to R1 due to changes in their diabetes management. It is alleged that the requests to relocate were made after citations related to the management of R1's medication were issued by the Department as part of the investigation of complaint 22-AS-20250402163711. Even though, the timing matches a potential retaliatory intent, the administrator also provided extensive documentation supporting their claim of a change in condition. There is therefore insufficient evidence to adequately corroborate that retaliation has been taking place. Regarding the allegation that Staff is being verbally inappropriate in front of facility residents, none of the three visits conducted allowed licensing staff to observe potential inappropriate verbal behavior from staff. A majority of residents interviewed denied having ever witnessed or been subjected to inappropriate verbal behavior. One staff and one resident interviewed appear to identify one potential staff member who could have made inappropriate comments without identify clear circumstances or providing sufficient evidence. The staff member in question is no longer employed by the facility. Regarding the allegation that Facility staff did not report health incidents appropriately to licensing staff, multiple incident reports for resident R1 were submitted to licensing staff as required during R1's period of admission. No specific instances of hospitalization or health incidents that would have failed to be reported were evidenced during the investigation. Regarding the allegation that Facility staff did not notify a resident's responsible party of a serious health incident, the following has been concluded: Based on staff interviews and a review of text and email communications between staff and R1's responsible party, licensing staff was able to establish a clear pattern of updates and communication regarding R1's health condition and management of the diabetes diagnosis. As a result, the allegations are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred.the state’s words, verbatim · CDSS document, Jan 15, 2026 · control 22-AS-20250613153014

Allegation investigated: Facility did not give proper notification of eviction

On this day, Licensing Program Analyst made an unannounced visit to the facility for the purpose of following up on the investigation of the three allegations listed above as well as to deliver findings to the facility. LPA was greeted and granted entry by administrator Faith Rasouli after stating the purpose of the visit. Allegations under review were listed during the visit. An initial complaint investigation visit was conducted by licensing staff on October 14, 2025. During the visit, LPA Rodriguez toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed. Additional witness interviews conducted during the investigation. During the present visit, LPA conducted a tour of the physical plant and reviewed resident records for six currently admitted individuals. CONTINUED ON FORM LIC9099-C Substantiated CONTINUED FROM FORM LIC9099 Regarding the allegation that Facility did not give proper notification of eviction, the following has been concluded: On October 10, 2025, facility administrator Faith Rasouli sent an email to the responsible party and attorney-in-fact for former facility resident R1 with the intention to notify the responsible party that R1's assessed care needs were no longer compatible with the care and supervision levels provided at the facility. However, upon review of the message, it was determined that the notice did not include the following elements as required by Section 87224 of the California Code of Regulation on Eviction Procedures: - A copy of the resident’s current service plan. - A list of referral agencies. - The right of the resident or resident’s legal representative to contact the department to investigate the reasons given for the eviction pursuant to Section 1569.35. - The contact information for the local long-term care ombudsman, including address and telephone number. As a result, the allegation is determined to be Substantiated, meaning that the preponderance of evidence standards has been met. A type B deficiency is cited on an attached form LIC9099-D. Administrator Faith Rasouli had to leave the premises before the conclusion of the visit and authorized caregiving staff Johnny Bugtong to sign the report on her behalf. An exit interview was conducted and a copy of this report along with appeal rights was provided to a facility representative. CONTINUED FROM FORM LIC9099 Regarding the allegation that Facility did not notify responsible party regarding resident's health condition, the following has been concluded: Based on staff interviews and a review of text and email communications between staff and R1's responsible party, licensing staff was able to establish a clear pattern of updates and communication regarding R1's health condition and management of the diabetes diagnosis. Administrator was however unable to trace back documentation that a toe infection had effectively been notified ahead of a specialist appointment during which it was additionally evidenced. There is insufficient evidence to corroborate or discard the allegation. As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to a facility representative. CONTINUED FROM FORM LIC9099 Regarding the allegation that Resident was issued an unlawful eviction, the following has been concluded: Based on interviews with the facility administrator as well as witnesses, it was determined that alternate placement was eventually found in order to better meet resident R1's care needs without resorting to a formal eviction. As a result, the allegation is determined to be Unfounded, meaning that the allegation is false, could not have happened and/or is without reasonable basis. An exit interview was conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 15, 2026 · control 22-AS-20251013161555

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(d)(1) · Plan of correction due date: Jan 29, 2026

Per CCR 87224(d)(1) The notice to quit shall include the following information: (B) Resources available to assist in identifying alternative housing and care options (...). This requirement was not met as evidenced by: Based on records reviewed, the notice served to R1's responsible party did not include the necessary elements detailed in Title 22. This constitutes a potential risk to the health, safety and personal rights of individuals in care.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: Licensee reviewed Section 87224 on Eviction Procedures and verbalized understanding the requirements. Deficiency cleared during the visit.

Type of visit: Required - 1 Year

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by facility administrator Faith Rasouli after stating the purpose of the visit. There are currently six residents in care, none of which are receiving hospice care at this time. Residents are observed relaxing in their respective bedrooms and in the common areas. LPA accompanied by facility staff toured the physical plant. The facility is a one-story house with six private bedrooms used by residents and one locked staff room. There are two bathrooms used by residents, including one en-suite bathroom located in one of the rooms. None of the residents are assessed to be bedridden at this time. Physician orders for residents using postural supports verified to be on file. One resident currently admitted to skilled nursing is noted to have full rails despite not receiving hospice care. Consultation provided. All occupied bedrooms appear clean and sanitary. All resident bedrooms have the required furnishings. Bathrooms appear clean and sanitary and are all equipped with grab bars and slip mats. Hot water temperature measured at 108.4F in the shared bathroom with faucets used for personal grooming by residents. LPA observed the kitchen has a minimum two (2) day perishable and seven (7) day non-perishable food supply. Sharp items, cleaning supplies and the medication central storage are verified to be secure. Two wall-mounted fire extinguishers are present and verified to be charged. Receipts for purchase are dated December 31, 2025. Carbon monoxide and smoke detectors are present and operational. CONTINUED ON FORM LIC809-C CONTINUED FROM FORM LIC809 LPA and facility staff toured the outside of the facility. LPA observed a shaded outdoor seating area with outdoor furniture for resident use in the backyard. There are no bodies of water on the premises. The identified routes of egress are free of clutter and obstructions. There are self-latching gates on both sides of the premises. The facility does not utilize either locked perimeters or delayed egress. LPA reviewed six resident records which were found to include all necessary elements of documentation. LPA reviewed resident medication records and prescription orders with no discrepancies observed for all six residents. However, the physician report for one of the residents diagnosed with insulin-dependent diabetes indicates the resident is assessed to be unable to manage their injections or glucose monitoring in spite of being fully alert with no indications of mild cognitive impairment. One type B deficiency issued. Clarification provided on the updated requirement for an annual medical assessment for residents. LPA reviewed staff records for six staff members during the visit. All staff members on the schedule are background cleared and associated. Proof of current CPR training reviewed. Annual and initial training reviewed. Disaster drills are conducted quarterly. The administrator certificate is current. Based on the observations conducted during the present visit, one type B deficiency is being cited per Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.the state’s words, verbatim · CDSS document, Jan 15, 2026

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting a case management inspection documenting an unrelated deficiency observed during the investigation of complaint 22-AS-20250613153014. During a record review conducted during the initial complaint investigation conducted on June 17, 2025, LPA observed that resident R1 was allowed to leave the premises independently in the presence of the taxi or non-emergency ambulance driver to attend medical appointments outside of the facility in spite of having been repeatedly assessed by their physician to be unable to leave the facility unassisted on multiple reports. Resident is essentially alert and oriented, however the discrepancy between their assessment and their actual functional capabilities was not observed by facility staff. A type B defiency is therefore cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Jan 15, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Jan 16, 2026

Per CCR 87466: "The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs." This requirement is not met as evidenced by: Based on records and interviews, it was evidenced that a discrepancy between R1's medical assessment and their functional capabilities was not flagged and brought to their physician's attention. This constitutes a potential risk to health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: Licensee requested an immediate reassessment which concluded that the resident was able to attend outside medical appointments with the assistance of the taxi driver. Report provided to licensing staff on 06/25/2025. Deficiency cleared.

Allegation investigated: Facility mismanaged resident's medication

On September 25, 2025, Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced visit to the facility to investigate the above allegation. Upon arrival, LPA Haddadin was greeted and granted entry by Johnny Bugeong. The investigation included staff and resident interviews, a review of facility records, and direct observations of the physical plant.LPA reviewed Resident 1’s (R1) medication records. Documentation reflected that R1’s medications were managed by the facility; however, insulin injections were to be self-administered by R1 with staff oversight only. On August 21, 2025, R1’s responsible party provided written instructions in preparation for scheduled lab work, directing that only Lantus insulin was to be administered, and Apidra insulin withheld. LPA verified these instructions through text message correspondence between the responsible party and the facility. {***CONTINUE 9099C***} Substantiated Despite this, records and interviews confirmed that staff permitted R1 to self-administer both medications.LPA interviewed two staff members, both of whom corroborated the allegation, including one who witnessed R1 self-administering both insulins. LPA also interviewed three residents. Due to cognitive limitations, residents were unable to provide relevant information regarding the allegation.Based on record review and staff interviews, the allegation that the facility mismanaged R1’s medication was substantiated. The preponderance of evidence standard has been met. One deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6. A copy of this report and appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, Sep 25, 2025 · control 22-AS-20250826132344

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 26, 2025

87465(a)(4) – Incidental Medical and Dental CareFacility staff shall assist residents with self-administration of prescription medications as needed ... shall be given in accordance with the physician’s instructions. Based on interviews and records review, the facility failed to follow physician instructions for (R1)despite clear instructions to administer only Lantus prior to R1's fasting laboratory appointment. This posed an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Sep 25, 2025

Plan of correction: Administrator shall retrain all staff on medication administration requirements, emphasizing that medications must be administered strictly according to physician instructions. Administrator shall also implement procedures for staff to double-verify physician orders prior to administering insulin. Documentation of training and verification procedures shall be submitted to by POC due date

Allegation investigated: Facility does not have the required posters for public display.

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Administrator (AD) Faith Rassouli and explained the reason for today’s inspection. The investigation into the allegation that facility does not have the required posters for public display revealed the following: During the course of the investigation, LPA inspected the facility and obtained and reviewed copies of the resident roster and staff roster. It was alleged that the facility does not have the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) displayed in the facility as required. LPA inspected the facility and observed the facility does have a PUB 475 posted. However, LPA observed that the PUB 475 is posted in the kitchen, instead of the main entryway of the facility as required, and LPA measured the PUB 475 to be approximately 17 inches by 22 inches, instead of 20 inches by 26 inches as required. The information obtained corroborated the allegation. Substantiated During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. It was alleged that R1’s prescription for Atorvastatin changed from 20MG to 10MG, the facility received both doses from the pharmacy in February 2025, the facility gave R1 both doses for multiple days despite the 20MG dose being discontinued, and in March 2025 the bubble packs for all of R1’s medications showed that R1 had missed multiple days of their medications. LPA inspected the facility, conducted health and safety checks on residents present, and observed no health and safety issues. LPA inspected the medications for all six residents did not observe any current medication errors. LPA reviewed R1’s Medication List and did not obtain information regarding the allegation. LPA interviewed AD who denied giving R1 both doses of Atorvastatin at the same time, stating that the 20MG dose was discontinued when the 10MG dose was received, and denied that R1 missed doses of their medications. One witness stated they observed staff trying to give R1 both doses of the Atorvastatin and prevented them from doing so. R1 stated that they recall receiving two doses of the Atorvastatin, but could not recall for how many days. However, AD and two staff denied that this occurred, instead claiming that when the new dose was received the old one was put to the side and replaced by the new dose. AD and two staff also stated that residents receive all their medications as prescribed. LPA reviewed staff training records which showed four out of four staff have up-to-date medication training. LPA interviewed the five other residents and did not obtain information corroborating any other issues with medications. No information was obtained indicating that R1 suffered any effects from the alleged medication error and interviews with AD and a witness revealed that R1’s Atorvastatin prescription has since been increased to 40MG, which is higher than both previous doses combined. The information obtained is conflicting. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jul 11, 2025 · control 22-AS-20250402163711

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(c)(2)(A) · Plan of correction due date: Jul 18, 2025

87468 Personal Rights… (c) Licensees shall prominently post (2) … (A) … the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) … 20" x 26" in size and be posted in the main entryway of the facility… Based on observation, the licensee did not ensure the PUB 475 was the correct size and in the entryway of the facility, which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 11, 2025

Plan of correction: The licensee has already posted a proper sized PUB 475 in the main entryway of the facility and LPA confirmed. POC CLEARED.

Type of visit: Case Management - Deficiencies

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20250402163711. LPA met with Administrator (AD) Faith Rassouli and explained the reason for today’s inspection. During the course of the investigation, LPA inspected the facility, interviewed AD, residents, staff, and witnesses, and obtained and reviewed copies of the resident roster, staff roster, and Resident #1’s (R1) Medication List. LPA interviewed AD who stated that R1’s prescription for Atorvastatin changed from 20MG to 10MG, the facility received both doses in November 2024 and January 2025, the facility did not notify the doctor, pharmacy, or R1’s family of the issue, and AD discarded the 20MG dose after it was replaced by the 10MG dose without keeping a medication destruction record. One witness interviewed stated that they learned that R1 had two doses of the same medication by observing it themselves and that they addressed the issue with R1’s doctor and pharmacy because the facility had not. LPA reviewed R1’s Medication List which shows that R1 received both doses of Atorvastatin in November 2024 and again in January 2025, which shows that the facility did not properly address the medication issue in November 2024 because both doses were received again January 2025. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jul 11, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(i) · Plan of correction due date: Aug 8, 2025

87465 … (i) Prescription medications which … are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record… This requirement was not met as evidenced by: Based on admission, the licensee destroyed R1’s 20MG Atorvastatin in February 2025 but did not keep a record, which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Jul 11, 2025

Plan of correction: Licensee stated they will conduct staff training on properly destroying medications and documenting the destruction and will submit proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(a)(1) · Plan of correction due date: Aug 8, 2025

87465 Incidental Medical and Dental Care (a) … (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on documents and admission, the licensee received multiple doses of the same medication for R1 but did not address this issue with R1’s family, doctor, or pharmacy, which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Jul 11, 2025

Plan of correction: Licensee stated they will conduct staff training on reviewing medications received for accuracy and potential issues and will submit proof to LPA by POC date.

Type of visit: Required - 1 Year

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the purpose of the visit. Administrator Fatimeh Rassouli was notified of the visit via telephone and arrived shortly afterwards to assist with the visit. There are currently six residents in care, none of which are currently receiving hospice care. LPA observed residents relaxing in their respective bedrooms or in the facility's common living areas. LPA accompanied by facility staff toured the physical plant. The facility is a one-story house with an attached garage accessed through the side yard. The facility has six private bedroom and two shared bathrooms in addition to one staff room which is kept inaccessible from residents in care. Bedrooms appeared clean and sanitary. Physician orders for all postural supports in use reviewed and verified to be on file. LPA observed all the resident bedrooms have the required furnishings. Bathrooms appear clean and sanitary. Bathroom are equipped with grab bars. Shower chairs are in use but no slip mats are present. Consultation provided. Hot water temperature measured at 118F in a bathroom with a faucet used for personal grooming. LPA observed the kitchen has a minimum two (2) day perishable and seven (7) day non-perishable food supply. Sharp items are stored in a secure drawer. Cleaning supplies are stored in the locked garage and in a secure cabinet under the kitchen sink. Fire extinguisher is charged and mounted. LPA tested the smoke and carbon monoxide detectors which were found to be operational. The centrally stored medication is located in a secure closet located in the administrative office. The attached garage is inaccessible to residents and is used for storage and laundry, with an additional refrigerator/freezer present. CONTINUED ON FORM LIC809-C CONTINUED FROM FORM LIC809 LPA and facility staff toured the outside of the facility. LPA observed an shaded outdoor seating area with furniture for resident use. The perimeter gates on both sides of the property are self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises. LPA reviewed six resident records which included all necessary components. LPA reviewed resident medication records and prescription orders for all admitted residents with no discrepancies observed. Three resident interviews conducted during the visit. There are three residents with physician orders for diabetes-related injections. The physician reports for two of those residents confirm the residents are able to self-administer with assistance. The third resident appears alert and oriented however the physician did not confirm the ability to self-administer safely. Licensee will reach out to the resident's primary care physician to get the assessment documented. Consultation provided. There are no bedridden residents present on the premises. LPA reviewed four staff records which were found to be complete. Annual training as well as CPR/First aid training reviewed and up-to-date. All staff are background cleared and associated to the licensed location accurately. Based on the observations made during today’s visit, one type B deficiency is being cited per Title 22 Division 6 of the California Code of Regulations and three consultations are provided. An exit interview was conducted and a copy of this report along with appeal rights was provided to a facility representative.the state’s words, verbatim · CDSS document, Feb 6, 2025

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit for the purpose of conducting a Required Annual Inspection. LPA was greeted and granted entry by caregiving staff after introducing himself and stating the purpose of the visit. Administrator Faith Rassouli was contacted by phone and arrived later to assist with the visit. During the inspection, LPA and administrator conducted a tour of the physical plant and observed the following: The facility is a one-level home with six resident bedrooms, one staff room and three full bathrooms. All resident bedrooms have the required furnishings. LPA observed all beds had linens and blankets and an adequate additional supply is present. The backyard has a shaded sitting area and the route of egress is free of clutter and obstructions. There are currently six residents in care at the facility, one of which is receiving hospice care. Bathrooms faucets and toilets were operational. Water temperature tested at approximately 110F degrees. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged with up-to-date maintenance. Sharps were observed locked in a drawer in the kitchen. LPA observed cleaning supplies to be stored in a locked cabinet under the kitchen sink. The laundry area is also observed to be secured. The medication central storage was observed to be locked. LPA reviewed six resident files and four staff files before conducting staff and resident interviews. Based on the observations made during today’s inspection, three type B deficiencies are being cited along with two Technical Assistance and one Technical Violation Advisory Notes per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report along with appeal rights was provided to a facility representative.the state’s words, verbatim · CDSS document, Feb 26, 2024

The state marks this report as 6 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff did not ensure adequate care and supervision was provided to resident in care Staff do not ensure adequate incontinence care is provided to resident in care

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the allegations listed above. LPA was greeted and granted entry by facility caregivers after explaning the purpose of the visit. Administrator Faith Rassouli was unavailable due to a medical emergency. Report was reviewed with caregiving staff. An initial complaint investigation visit was conducted on November 15, 2023. LPA conducted a review of records for resident R1 kept at the facility as well as interviews with administrator and one present staff members were additionally conducted in addition to a tour of the physical plant. A follow-up investigation visit was held on January 18, 2024. During the visit, it was determined that R1 no longer resided at the facility. An additional staff interview was conducted then. A collateral visit for the purpose of attempting to interview the alleged victim took place on January 26, 2024 at another licensed facility. CONTINUED ON FORM LIC9099-C Substantiated CONTINUED FROM FORM LIC9099-A Regarding the allegation of an Illegal Eviction, the following has been concluded: Based on records reviewed and interviews conducted, a 30-notice to vacate served by the facility administrator was found to fulfil the regulatory requirements of Title 22 regulations by licensing staff. However, it was also determined that resident R1 was not evicted, but voluntarily moved to a more adequate facility with the assistance of a care coordinated agency. No eviction actually took place. As a result, the allegation is found to be Unfounded, meaning that meaning that the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided to a facility representative. CONTINUED FROM FORM LIC9099-A Regarding the allegation that Staff do not ensure resident is kept in clean dry clothing at all times, the following has been concluded: The allegation is identical to the allegation that Staff do not ensure adequate incontinence care is provided to resident in care which was Substantiated and for which a type A citation was issued. In order not to cite the facility twice for the same deficiency, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. Regarding the allegation that Staff handled resident in a rough manner, the following has been concluded: Based on interviews conducted, multiple statements regarding potential rough handling of resident R1 by a facility former staff member were made. However, multiple contradictory statements were also made and no injury was evidence. There is therefore insufficient evidence to prove that the incident did occur, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. Regarding the allegation that Staff did not safeguard residents personal property, the following has been concluded: Several personal items belonging to R1 were reported as missing such as cosmetic products. Records reviewed indicated that the items in question had not been placed under the facility's safeguarding responsibility inventoried upon admission. Additionally, multiple lost items were later found in the resident's bedroom, and safeguarding solutions in the form of a lockbox were put into place. As a result, there is insufficient evidence to indicate that the facility was deficient, The allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of this report was provided to a facility representative. CONTINUED FROM FORM LIC9099 Regarding the allegation that Staff do not ensure adequate incontinence care is provided to resident in care, the following has been concluded: Based on interviews conducted and records reviewed, the facility does not provide routine care between the hours of 10pm and 6:30am, with the exception of non-routine, urgent needs being noted. It was however determined that it was a routine occurrence for facility staff to try to prevent R1's incontinence issues with the simultaneous use of multiple diapers at once rather than proceed to routine diapers changes throughout the night. Facility staff admitted to the practice which was also reported by hospital staff upon the resident's admission to the emergency department. The occurrence of a urinary tract infection can also be related to the practice. As a result, the allegation is found to be Substantiated, meaning that the preponderance of evidence standard has been met. A type A citation is issued in regard to the deficiency. Regarding the allegation that Staff did not ensure adequate care and supervision was provided to resident in care, the following has been concluded: Based on staff interviews, it was determined that after notifying a resident's responsible party that the facility was no longer suited to address the resident's need for nightly assistance, no modification to the resident's actually delivered care were made, thus not adequately meeting the resident's needs at the time. The allegation is therefore found to be Substantiated, meaning that the preponderance of evidence standard has been met. A type A citation is issued in regard to the deficiency. An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.the state’s words, verbatim · CDSS document, Jan 26, 2024 · control 22-AS-20231106143648

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87625(b)(2) · Plan of correction due date: Jan 27, 2024

CCR Section 87625(b)(2) on Managed Incontinence states that "(...) the licensee shall be responsible for (...) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night". This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, facility staff had adopted the practice of stacking diapers at night rather than conduct routine checks. This poses an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jan 26, 2024

Plan of correction: Licensee to provide statement that updated policies and training will be conducted regarding nightly care for incontinent residents.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.2(c) · Plan of correction due date: Jan 27, 2024

Per the Health & Safety Code: "(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, or welfare would be endangered. (...) This requirement is not met as evidenced by: Based on interviews conducted, no routine checks of the resident's hygiene were implented after it became evident that nightly incontinence was present. This poses an immediate to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Jan 26, 2024

Plan of correction: Licensee to provide statement that updated policies and training will be conducted regarding nightly care for incontinent residents.

Allegation investigated: Staff did not notify resident's authorized representative of resident's change in health conditions.

Licensing Program Analyst (LPA) Jerome Haley made unannounced visit regarding the complaint allegation above. LPA Haley was granted entry and explained the reason for the visit. The complaint investigation consisted of a review of resident records, Memorial Care Saddleback records, St. Rose of Lima Home health records, interviews with facility staff, residents, Hospice and Home Health providers. Regarding the allegation Staff did not notify resident's authorized representative of resident's change in health conditions. It was discovered Licensee/Administrator Faith Rasouli was in contact with Resident 1’s (R1) responsible party regarding R1’s health in the days prior to R1 being sent to the hospital. Review of text messages between Administrator Rasouli and the responsible party reveal the two individuals were in regular contact regarding R1, visiting status of the facility, and the COVID-19 virus. Continued on LIC9099C Unfounded Text message review show Licensee/Administrator Rasouli would send routine updates regarding the spread of the Coronavirus, updates regarding visiting family members at the facility, and updates on R1's health. In a text message dated December 16, 2020, Licensee/Administrator Rasouli notified R1’s responsible party that R1's appetite was less than normal, R1 was quiet, and had a cough. The responsible party was informed R1’s physician was informed about R1’s recent change in condition. Additional text messages were exchanged regarding R1’s change in condition on December 18, 2020. After R1 was admitted to the hospital December 20, 2020, additional text messages were exchanged until December 22, 2020. During a review of MemoriaCare Medical Center records, it was clear R1's responsible party was provided updates on R1 health during R1's entire time at the facility. According to a Nurse Practitioner (NP), R1’s responsible party stated, the patient (R1) is doing well at the board and care until February 2020 when R1 fell and fractured the right hip. R1 was sent to rehab until mid-March. R1 then went back to the board and care, was placed on hospice and was doing well. R1’s responsible party also agreed that after R1’s hospital visit, going back to the board and care with hospice would be best for the patient, after treatment is completed. During an interview with a Nurse from California Mission Hospice, LPA Haley was informed that R1’s physician and family are notified after every visit. According to the Nurse, R1's last visit from California Mission Hospice was December 16, 2020. Based on the information gathered during the investigation through interviews and document review, the allegation mentioned above is deemed UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 28, 2023 · control 22-AS-20201228104338

Allegation investigated: Resident was severely dehydrated due to neglect Staff did not ensure resident is being fed

Licensing Program Analyst (LPA) Jerome Haley made unannounced visit regarding the complaint allegations above. LPA Haley was granted entry and explained the reason for the visit. The complaint investigation consisted of a review of resident records, MemorialCare Saddleback Medical Center records, St. Rose of Lima Home Health records, interviews with facility staff, facility residents, Hospice and Home Health providers. Regarding the allegations: Resident was severely dehydrated due to neglect and Staff did not ensure resident is being fed, during the investigation 10 of 11 individuals either denied the allegations and/or were unable to verify the allegations to be true. Interviews and record review reveal, on December 20, 2020, caregivers informed Licensee/Administrator Faith Rasouli Resident 1 (R1) had not eaten since December 19, 2020. Continued on LIC9099C Unsubstantiated Resident 2 (R2) was interviewed regarding the complaint allegations and R2 confirmed R1 would come to the table and eat with the rest of the residents. R2 stated the caregivers would give all the residents the same amount of food and something to drink. Based on the information gathered during the investigation through interviews and document review, the Department is unable to ascertain if the allegations: Resident was severely dehydrated due to neglect and Staff did not ensure resident is being fed, occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, both allegations are deemed Unsubstantiated. Licensee/Administrator Rasouli contacted R1’s responsible party and informed them of the change in condition and requested to send R1 to the hospital due to the change in condition. A review of MemorialCare Saddleback Medical Center records indicate Resident 1 (R1) was admitted December 20, 2020. R1 was assessed and active problems were discovered: Pneumonia/COVID 19 (Principal Problem) Acute respiratory failure with hypoxia Senile dementia without behavioral disturbance Oral phase dysphagia Severe protein-calorie malnutrition Encephalopathy due to COVID-19 virus Pressure ulcer of left heel, unstageable A review of MemorialCare Medical Center progress notes by Physician 1 (P1), dated December 22, 2020, stated the following: Patient has profound dysphagia unable to initiate eating and without demonstrated ability to swallow safely. This is likely the result of end stage dementia more so than COVID-19 infection though the latter is contributing. Dysphagia and disinterest in eating is a chronic process as witnessed by 25-pound weight loss since February 2020 and chronic hypernatremia that demonstrated insufficient free water intake. I advised patients [responsible person] that the patient is at the end of life. Treatment for COVID-19 was unlikely to turn around what has been a chronic and slow process that began before any infection. Interviews with facility staff members, California Mission Hospice Nurse, and a home Health Nurse all revealed R1 was fed, and the resident’s appetite would vary. According to the Hospice Nurse, R1 was eating 80% – 90% of his meals. December 16, 2020, was the last time Hospice visited R1 and it was reported the resident was eating 60% - 70% of his meals. A Home Health Nurse revealed R1 had a good appetite, but R1 did lose weight due to his dementia diagnosis. Continued on LIC9099Cthe state’s words, verbatim · CDSS document, Dec 28, 2023 · control 22-AS-20201228104338

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Jerome Haley conducted a case management visit regarding the status of the physical plant. While investigating complaint control # 22-AS-20201228104338 an unannounced visit was made and during the tour of the facility LPA Haley noticed some areas in the kitchen that needed cleaning and some areas that needed repair. Dusty was observed in the kitchen on the cabinets above the stove. Dust was observed on top of the refrigerator and covered the items sitting there. Microwave was in disrepair. The door would not close properly Cabinet on the right side of the stove missing the cabinet door. During the visit Licensee Rasouli called repairmen who arrived during the visit and cleaned the dusty areas of the kitchen and made repairs to the cabinets. Licensee Rasouli already ordered a new microwave to replace the broken one in the kitchen. Licensee Rasouli was advised on the importance of keeping the facility clean and in good repair at all times. No deficiencies are being cited during today's Case Management visit. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 7, 2023